This paper reports on HIV-related risk activities among 95 people with severe mental illness in psychiatric care in New York City

Cournos, Francine

Guido, Jeannine R.

McKinnon, Karen M.

Meyer, Ilan

Meyer-Bahlburg, Heino F. L.

English

Columbia University Academic Commons

HIV Risk Activity AmongPersons With Severe MentalIllness: Preliminary FindingsReferences1104 November 1993 Vol. 44 No. 11 Hospital and Community Psychiatryeach coping-skills module. Coping-skills training should be used withgroups of schizophrenic patients inother settings. In addition to goal at-tainment, the impact of coping-skills training on symptomatologyand domains of functioning shouldbe assessed.Results of this study suggest theusefulness ofcognitivc interventionswith schizophrenic patients. Cop-ing-skills training provides a poten-tially valuable means to enhanceschizophrenic patients’ ability tocope with stress and provides apromising approach that can aug-ment traditional treatment of schizo-phnenia.1 . Anthony W, Cohen M, Vitalo R: Themeasurement ofrehabilitation outcome.Schizophrenia Bulletin 4:365-383,19782. Zukoff D, Snyder K, Ventura J, et al:Life events, familial stress, and coping inthe developmental course of schizophre-nia. Schizophrenia Bulletin 10:258-292, 19843. ZubinJ: Possible implications ofthevul-nerability hypothesis for the psychoso-cial management of schizophrenia, inPsychosocial Management of Schizo-phrenia. Edited by Strauss J. Toronto,Huber, 19864. Tallant S, Rose 5, Tolman R: New cvi-dence for the effectiveness ofstress man-agement training in groups. BehaviorModification 13:431-446, 19895. Subramanian K: Structured group workfor the management ofchronic pain. Re-search on Social Work Practice 1:32-46,19916. Tolman R, Rose 5: Coping with stress: amultimodal approach. Social Work 3:151-158, 19857. D’ZurillaT, Goldfried M: Problem solv-ing and behavior modification. Journalof Abnormal Psychology 78: 107-1 26,19718. Wallace C, Boone 5: Cognitive factors inthe social skills ofschizophrenic patients.Nebraska Symposium on Motivation 31:283-318, 19909. Kiresuk TS, Sherman RE: Goal Attain-ment Scaling: a general method for eval-uating comprehensive community men-tal health programs. Community MentalHealthJournal 4:443-453, 196810. Beidel D, Turner S, Bellack A, et al:Using the GoalAttainment Scale to mea-sure treatment outcome in schizophre-nia. InternationalJournal ofPartial Hos-pitalization 2:33-41, 1982Francine Cournos, M.D.Karen McKinnon, M.A.Heino Meyer-Bahlburg, Dr.Rer. Nat.Jeannine R. Guido, M.A.Ilan Meyer, M.A., M.Phil.HIV senoprevalence rates between5 . 5 percent and 8.9 percent havebeen reported among hospitalizedpsychiatric patients in New YorkCity (1,2). The prevalence oftwo keyHIV-nisk activities in this popula-tion, unsafe sex and drug injection,has not been adequately investi-gated.At two public psychiatric hospi-tals, charted histories of homosexualactivity were found for 18 of 237men (7.6 percent), and drug injec-tion was documented for 39 of 451men and women (8.6 percent) (1).Using written questionnaires, onestudy found that nearly half of 113acutely hospitalized psychiatric pa-tients reported a history of HIV-re-lated risk behaviors during the previ-ous five years (3). In another study atan inner-city outpatient psychiatricclinic, more than half of 60 patientshad engaged in risk behaviors in thepast year (4). Most risk behaviorswere related to unsafe sexual activi-ties. Rates of injection-drug use dur-ing the period under investigationwere 5 percent in both studies (3,4).Psychiatric diagnoses may affectrisk behavior. Patients with bipolardisorder have been observed to expe-nience periodic hypenscxuality (2).Chronic psychopathology among pa-The authors are affiliated with theNew York State Psychiatric Insti-tute, 722 West 168th Street, NewYork, New York 10032, and thedepartment of psychiatry at theCollege of Physicians and Sur-geons of Columbia University.tients with schizophrenia may de-crease the frequency of sexual activ-ity (5) and use of narcotics (6).The objective of the study ne-ported here was to assess risk behav-ions associated with HIV infectionamong severely mentally ill personsusing carefully established researchdiagnoses and lengthy face-to-faceinterviews about risk behaviors.MethodsAll patients between the ages of 18and 59 who were judged by the treat-ing clinician to be capable of con-senting to research were approachedat three sites that provide services toseverely and persistently mentally illpersons. Of the 264 patients ap-proached, 200 agreed to participate,an acceptance rate of 76 percent.This paper reports findings for thefirst 95 patients who completed in-terviews.Study sites were a day treatmentprogram, an acute inpatient unit,and a state hospital unit that pre-pares patients for community living.At all sites it was the policy to cx-dude from treatment persons withprimary diagnoses of substance usedisorders. Participants had recentopportunities for sexual activity anddrug use off hospital grounds.Each consenting patient under-went a structured set of face-to-faceinterviews. Each assessment con-sisted of the Structured Clinical In-terview for DSM-III-R (7); an adap-tation of the Panenteral Drug UseHigh-Risk Questionnaire (8), whichis an interview about use of injectiondrugs, and the Sexual Risk BehaviorAssessment Schedule, which elicitsdetailed information about behaviorsin the preceding six months andsome information about lifetime sex-ual history (9). The sexual interviewwas designed to put patients at casewhen talking about sex and con-Table IH1V risk behaviors among 95 patients with severe mental illness, by diagnostic groupSchizo-phreniaBipolardisorder Other Total(N=47) (N=17) (N=31) (N=95)Riskbehavior N % N % N % N %Homosexual activityPastsixmonths 2 4.3 0 - 0 - 2 2.1Lifetime 10 21.3 2 11.8 5 16.1 17 17.9Drug injectionPast six months 0 - 0 - 1 3.2 1 1.1Sincel978 9 19.1 4 23.5 6 19.4 19 20.0Heterosexual activity,past six monthsAbstinent 22 46.8 6 35.3 12 38.7 40 42.1Onepartner 10 21.3 5 29.4 11 35.5 26 27.4Multiple partners 15 31.9 6 35.3 8 25.8 29 30.5Condom use, past sixmonths2Among subjects reportingone sexual partnerNocondomuse 5 62.5 3 60.0 9 90.0 17 74.0Inconsistent use 1 12.5 1 20.0 1 10.0 3 13.5Consistent use 2 25.0 1 20.0 0 - 3 13.5Among subjects reportingmultiple sexual partnersNocondomuse 6 40.0 2 40.0 3 37.5 11 39.3Inconsistent use 8 53.3 2 40.0 5 62.5 15 53.6Consistent use 1 6.7 1 20.0 0 - 2 7.1I Diagnoses include schizoaffective disorder, major depressive disorder, psychotic disorder nototherwise specified, and atypical psychosis.- Condom use data were missing for some patients.Hospital and Community Psychiatry November 1993 Vol. 44 No. 11 1105tamed techniques for improving ac-curacy ofrecall. The reliability of se-lected variables from this instrumenthas been demonstrated with psychi-atnic patients (10). Chi square analy-ses were used to test differences be-tween groups.ResultsSample characteristics. Of the 95participants, 53 (55.8 percent) werefrom the community preparationunit, 27 (28.4 percent) from the daytreatment unit, and 15 (15.8 per-cent) from the acute care unit. Dc-mographically and clinically, partic-ipants reflected the census in thesesettings.The mean±SD age ofpatients was35 .4±8.4 years. The mean number ofprevious psychiatric hospitalizationswas 5.1±5.2. Fifty-nine of the pa-tients (62 percent) were men. A totalof 43 patients (45.3 percent) wereblack, 26 (27.4 percent) were Hispa-nic, and 26 were either white or fromother ethnic groups.Riskfactors. No significant dif-ferences in sexual activity were foundbetween patients at the three sites,including being abstinent, havingmore than one partner in the previ-ous six months, or using condoms.Nor were differences in injection-drug use found. Therefore, patientdata from the three sites were com-bined for subsequent analyses.Table 1 shows risk characteristicsof the 95 participants by diagnosticgroup: schizophrenia, bipolar disor-der, and other diagnoses (schizoaffec-tive disorder, major depressive disor-den, psychotic disorder not otherwisespecified, and atypical psychosis).No significant differences betweenthe diagnostic groups were found inthe rate ofabstinence, number of sex-ual partners, condom use, homosex-ual behavior, or drug injection.Recent sexual activity. Overall,55 patients (57.8 percent) reportedengaging in sexual activity duringthe past six months. Thirty-two of59 male patients (54.2 percent) and23 of36 female patients (63.9 per-cent) reported recent sexual activity.No significant differences betweenmen and women were found in therate ofabstinence, number of part-ners, or condom use during vaginalor anal intercourse.Age, gender, and ethnicity werenot significantly associated withbeing sexually active. However, sex-ually active patients under age 40were significantly more likely tohave multiple partners than thoseover age 40. In the younger group,15 patients (37.5 percent) had onesexual partner, and 25 (62.5 percent)had multiple partners. Among pa-tients age 40 or older, 1 1 (73.3 per-cent) had one sexual partner, and four(26.7 percent) had multiple partners(X2=4.27, df= 1 , p= .04, Yates’ conti-nuiry correction).Condom use during heterosexualvaginal and anal intercourse was ana-lyzed for 5 1 patients for whom com-plete information was available.Only five patients (9.8 percent) re-ported using condoms for each act ofintercourse. Twenty-eight patients(54.9 percent) never used condoms.The remaining 18 patients (35.3percent) used condoms inconsis-tently. Condom use did not vary sig-nificantly by age, gender, or ethnicgroup. Patients with multiple part-ners were more likely to use condomsthan those who were monogamous.Eleven of 28 patients (39.3 percent)who never used condoms reportedhaving multiple partners, while 17of 23 patients (73.9 percent) whoused condoms, albeit inconsistently,had multiple partners (X2=6.11,df= 1, p=.Ol).Heterosexual anal intercourse wasreported by seven of 3 1 men (22.6percent) and five of 23 women (21.7percent). None ofthc men and two ofthe women used condoms.Homosexual history. Only two(3.6 percent) ofthe 55 sexually activepatients (one man and one woman)reported current homosexual activ-ity. These two patients also reportedheterosexual activity during the pastsix months. No patient reported ho-1106 November 1993 VoL 44 No. 11 Hospital and Community Psychiatrymosexual activity exclusively or ho-mosexual anal intercourse.Seventeen (18.5 percent) ofthe 92patients for whom complete infon-mation was available reported homo-sexual behavior at some time in thepast; 1 1 of 58 men (19 percent) andsix of 34 women (17.6 percent) re-ported such past behavior. Ten of thepatients were currently sexually ac-tive, but only one reported currenthomosexual behavior.Drug injection. Of the 95 pa-tients, only one reported drug injec-tion in the previous six months, shar-ing injection equipment once duringthat time. Drug injection at leastonce since 1978 was reported by 19patients (20 percent).-1 3 men (22percent) and six women (16.7 per-cent). No significant association wasfound between drug injection andage, gender, ethnicity, or psychiatricdiagnosis.Discussion and conclusionsThis study of HIV risk behaviorsamong severely mentally ill patientsyielded some surprising findings.First, rates of sexual activity anddrug injection were not related to di-agnosis. Despite previous reportssuggesting that differences might befound, bipolar disorder was not asso-ciated with a greater likelihood ofsexual activity, nor schizophreniawith abstinence or lower rates ofdrug injection.Second, unsafe heterosexual activ-ity was by far the most common cur-rent risk behavior, rather than theclassical risk factors of male homo-sexual activity and drug injection.However, past participation in bothhomosexual activity and drug injec-tion were more impressive than cur-rent participation in these activitiesmight suggest, and, despite thetreatment sites’ exclusion of individ-uals with a primary diagnosis of asubstance use disorder, a surprising20 percent of all patients had in-jected drugs at least once since 1978.A third unexpected finding wasthat younger age did not predict sex-ual activity, although younger pa-tients were more likely to have mul-tiple partners. Only 9.8 percent ofsexually active patients consistentlyused condoms.The patients in our study had anaverage of five previous psychiatrichospitalizations. These findings maynot be applicable to patients who aremore acutely ill on who have milderillnesses. Non may they be applicableto patients outside ofurban settings.An additional limitation is the lackofinformation about patients not re-ferred to this research project becausethey were deemed unable to giveconsent. Although our patients ap-peared to be comfortable answeringvery explicit sexual questions, wecannot exclude the possibility thatthe low rates of current homosexualactivity represented underreporting.In conclusion, unprotected het-enosexual intercourse was the mostfrequent current HIV risk activity inthis group ofpatients with chronicmental illness. However, past use ofinjection drugs and homosexual ac-tivity were important factors in thesample. Although these behaviorswere less frequent, they may rcpnc-sent more serious risk factors becauseHN may be more easily transmittedby these routes. In our experience,patients are willing and able to dis-cuss HIV risk behaviors, whichshould permit the development andimplementation ofappropniately tar-geted risk reduction interventions.AcknowledgmentsThis study was supported by grant MH-4625 1 from the National Institute ofMental Health and by the New YorkState Office of Mental Health. The au-thors thank Louis Caraballo, DianeEngel, M.S.W., Elizabeth Margoshes,Ph.D., Brenda Agosin, M.A., and thestaff of the Washington Heights Com-munity Service.References1. Cournos F, Empfield M, Horwath E, et al:HIV seroprevalence among admissions attwo psychiatric hospitals. American Jour-nal ofPsychiatry 148:1225-1230, 19912. VolavkaJ, Convit A, Czobar P. et al: HWseroprevalence and risk behaviors in pay-chiatric inpatients. Psychiatric Research39:109-114, 19913. SacksMH,PerryS,GraverR,etal:Self-reported HP/-related risk behaviors inacute psychiatric inpatients: a pilot study.Hospital and Community Psychiatry 41:1253-1255, 19904. Kelly JA, Murphy DA, Bahr GR: AIDS!HIV risk behavior among the chronicmentally ill. AmericanJournal of Psychi-atry 149:886-889, 19925. Lyketsos G, Sakka P, Mailis A: The sexualadjustment of chronic schizophrenics: apreliminary study. British Journal ofPsychiatry 143:376-382, 19836. Kay SR. Kalathara M, Meinzer AE: Di-agnostic and behavioral characteristics ofpsychiatric patients who abuse sub-stances. Hospital and Community Psy-chiatry 40:1062-1064, 19897. Spitzer RI, Williams JBW, Gibbon M:The Structured Clinical Interview forDSM-III-R (SCID). New York, NewYork State Psychiatric Institute, Biomet-rics Research, 19868. Williams JBW, Rabkin J, Remien R:Paraenteral Drug Use High-Risk Ques-tionnaire. New York, New York StatePsychiatric Institute, HIV Center, 19899. Meyer-Bahlburg HFL, Ehrhardt AA,Exner TM, et a!: Sexual Risk BehaviorAssessment Schedule, Psychiatric Inpa-tient Interview. New York, New YorkState Psychiatric Institute, HIV Center199010. McKinnon K, Cournos F, Meyer-Bahl-burg HFL, et al: Reliability ofsexual riskbehavior interviews with psychiatric pa-tients. American Journal of Psychiatry,150:972-974, 1993LettersLetters from readers are wekomed.They will be published at the dis-cretion of the editor as space per-mits and will be subject to editing.They should be a maximum of 500u,tv1s with no more thanfive refer-ences and should be submitted induplicate. Letters should be ad-dressed toJobn A. Talbott, M.D.,Editor, H&CP, APA, 1400 KStreet, N.W, Washington, D.C.20005.Helping Mentally Ill MothersTo the Editor: In the May issueNicholson and associates (1 ) reportedthe findings ofa survey ofstatc men-tal health departments aimed atidentifying state policies and pro-grams focused on the needs of men-tally ill mothers with preschool-agechildren. In Illinois, the task of fund-ing and delivering programming forat-risk children has fallen by defaultto the Illinois Department of Chil-dren and Family Services. The Illi-nois Department of Mental Healthrefused to assume responsibility in

HIV Risk Activity Among Persons With Severe Mental Illness: Preliminary Findings

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HIV Risk Activity Among Persons With Severe Mental Illness: Preliminary Findings

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